Interventions targeted at primary care practitioners to improve the identification and referral of patients with co-morbid obesity: a realist review protocol

<b>Background </b>Obesity is one of the most significant public health challenges in the developed world. Recent policy has suggested that more can be done in primary care to support adults with obesity. In particular, general practitioners (GPs) and practice nurses (PNs) could improve the identification and referral of adults with obesity to appropriate weight management services. Previous interventions targeted at primary care practitioners in this area have had mixed results, suggesting a more complex interplay between patients, practitioners, and systems. The objectives of this review are (i) to identify the underlying ‘programme theory’ of interventions targeted at primary care practitioners to improve the identification and referral of adults with obesity and (ii) to explore how and why GPs and PNs identify and refer individuals with obesity, particularly in the context of weight-related co-morbidity. This protocol will explain the rationale for using a realist review approach and outline the key steps in this process. <p></p> <b>Methods</b> Realist review is a theory-led approach to knowledge synthesis that provides an explanatory analysis aimed at discerning what works, for whom, in what circumstances, how, and why. In this review, scoping interviews with key stakeholders involved in the planning and delivery of adult weight management services in Scotland helped to inform the identification of formal theories - from psychology, sociology, and implementation science - that will be tested as the review progresses. A comprehensive search strategy is described, including scope for iterative searching. Data analysis is outlined in three stages (describing context-mechanism-outcome configurations, exploring patterns in these configurations, and developing and testing middle-range theories, informed by the formal theories previously identified), culminating in the production of explanatory programme theory that considers individual, interpersonal, and institutional/systems-level components. <p></p> <b>Discussion </b>This is the first realist review that we are aware of looking at interventions targeted at primary care practitioners to improve the weight management of adults with obesity. Engagement with stakeholders at an early stage is a unique feature of realist review. This shapes the scope of the review, identification of candidate theories and dissemination strategies. The findings of this review will inform policy and future interventions. Systematic review registration PROSPERO CRD4201400939

The role of primary care in adult weight management: qualitative interviews with key stakeholders in weight management services

Background: Primary care has a key role to play in the prevention and management of obesity, but there remain barriers to engagement in weight management by primary care practitioners. The aim of this study was to explore the views of key stakeholders in adult weight management services on the role of primary care in adult weight management. Methods: Qualitative study involving semi-structured interviews with nine senior dietitians involved in NHS weight management from seven Scottish health boards. Transcripts were analysed using an inductive thematic approach. Results: A range of tensions were apparent within three key themes: weight management service issues, the role of primary care, and communication with primary care. For weight management services, these tensions were around funding, the management model of obesity, and how to configure access to services. For primary care, they were around what primary care should be doing, who should be doing it, and where this activity should fit within wider weight management policy. With regard to communication between weight management services and primary care, there were tensions related to the approach taken (locally adapted versus centralised), the message being communicated (weight loss versus wellbeing), and the response from practitioners (engagement versus resistance). Conclusions: Primary care can do more to support adult weight management, but this requires better engagement and communication with weight management services, to overcome the tensions highlighted in this study. This, in turn, requires more secure, sustained funding. The example of smoking cessation in the UK, where there is a network of well-resourced NHS Stop Smoking Services, accessible via different means, could be a model to follow

Spatial prediction and spatio-temporal modelling on river networks

The application of existing geostatistical theory to the context of stream networks provides a number of interesting and challenging problems. The most important of these is how to adapt existing theory to allow for stream, as opposed to Euclidean, distance to be used. Valid stream distance based models for the covariance structure have been denied in the literature, and this thesis explores the use of such models using data from the River Tweed. The data span a period of twenty-one years, beginning in 1986. During this time period, up to eighty-three stations are monitored for a variety of chemical and biological determinands. This thesis will focus on nitrogen, a key nutrient in determining water quality, especially given the Nitrates Directive (adopted in 1991) and the Water Framework Directive(adopted in 2002). These are European Union legislations that have set legally enforcable guidelines for controlling pollution which national bodies must comply with. The focus of analysis is on several choices that must be made in order to carry out spatial prediction on a river network. The role of spatial trend, whether it be based on stream or Euclidean distance, is discussed and the impact of the bandwidth of the estimate of nonparametric trend is explored. The stream distance based "tail-up" covariance model structure of Ver Hoef and Peterson (2010) is assessed and combined with a standard Euclidean distance based structure to form a mixture model. This is then evaluated using crossvalidation studies in order to determine the optimum mixture of the two covariance models for the data. Finally, the covariance models used for each of the elements of the mixture model are explored to determine the impact they have on the lowest root mean squared error, and the mixing proportion at which it is found. Using the predicted values at unobserved locations on the River Tweed, the distribution of yearly averaged nitrate levels around the river network is predicted and evaluated. Changes through the 21 years of data are noted and areas exceeding the limits set by the Nitrates Directive are highlighted. The differences in fitted values caused by using stream or Euclidean distance are evident in these predictions. The data is then modelled through space and time using additive models. A novel smoothing function for the spatial trend is defined. It is adapted from the tail-up model in order to retain its core features of flow connectivity and flow volume based weightings, in addition to being based on stream distance. This is then used to model all of the River Tweed data through space and time and identify temporal trends and seasonal patterns at different locations on the river

Dental aspects of stigma in relation to mental and physical handicap in a Chinese population of Hong Kong.

PhDThe purpose of this study was to investigate the stigma of mental and physical handicap and its affects on the provision of dental care. Three groups of mentally and physically handicapped children, 4 year olds (n = 309), 14 year olds (n = 174) and 25 to 35 year olds (n = 265), were randomly selected from institutions in Hong Kong. The sample was dentally examined and dental status and treatment need assessed Their parents were also interviewed. Two psychometric scales, the Scale to Determine Attitudes Toward Disabled Persons (SADP), and the Parental Attitude Scale, a scale derived for this study, were used to assess attitude towards disabled persons in general, and specifically towards their own child. A questionnaire was also developed investigating parental experiences and feelings towards their handicapped child. Socioeconomic data was also collected and Information on the dental care delivery pattern experienced by their child. Dental practitioner members of the Hong Kong Dental Association were circulated with the SADP, the Dental Practitioner Attitude Scale, a scale derived for this study, and a questionnaire relating to qualifications and practice. A 62.5% response rate was achieved Canes experience was comparable to the non handicapped in the 4 year old group, lower in the other age groups, but with a high D component m the 25 to 35 year olds. Dental utilisation was low, the main reasons being financial, transport problems and a belief that the dentist would not treat. There was a gradation of parental attitude towards handicapped persons corresponding to education, age and socioeconomic factors. Dentists were not enthusiastic about treating handicapped patients for mainly financial reasons. Both parents and dentists felt strongly that government should provide facilities and be responsible for the treatment of handicapped individuals. The hypothesis of the study was mainly fulfilled. The stigma of handicap is a barrier to dental care, but is more socioeconomic than the way that handicapped persons present themselves

Geochemical associations of metals and organic matter in west coast Scottish sediments

SIGLEAvailable from British Library Document Supply Centre- DSC:D83224 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Patient and practice characteristics predicting attendance and completion at a specialist weight management service in the UK: a cross-sectional study

Objective: To determine the association between patient and referring practice characteristics and attendance and completion at a specialist health service weight management service (WMS). Design: Cross-sectional study. Setting: Regional specialist WMS located in the West of Scotland. Participants: 9677 adults with obesity referred between 2012 and 2014; 3250 attending service and 2252 completing. Primary and secondary outcome measures: Primary outcome measure was attendance at the WMS; secondary outcome was completion, defined as attending four or more sessions. Analysis: Multilevel binary logistic regression models constructed to determine the association between patient and practice characteristics and attendance and completion. Results: Approximately one-third of the 9677 obese adults referred attended at least one session (n=3250, 33.6%); only 2252 (23%) completed by attending four or more sessions. Practice referrals ranged from 1 to 257. Patient-level characteristics were strongest predictors of attendance; odds of attendance increased with age (OR 4.14, 95% CI 3.27 to 5.26 for adults aged 65+ compared with those aged 18–24), body mass index (BMI) category (OR 1.83, 95% CI 1.56 to 2.15 for BMI 45+ compared with BMI 30–35) and increasing affluence (OR 1.96, 95% CI 1.17 to 3.28). Practice-level characteristics most strongly associated with attendance were being a non-training practice, having a larger list size and not being located in the most deprived areas. Conclusions: There was wide variation in referral rates across general practice, suggesting that there is still much to do to improve engagement with weight management by primary care practitioners. The high attrition rate from referral to attendance and from attendance to completion suggests ongoing barriers for patients, particularly those from the most socioeconomically deprived areas. Patient and practice-level characteristics can help us understand the observed variation in attendance at specialist WMS following general practitioner (GP) referral and the underlying explanations for these differences merit further investigation

Community hospitals – the place of local service provision in a modernising NHS: an integrative thematic literature review

Background: Recent developments within the United Kingdom's (UK) health care system have reawakened interest in community hospitals (CHs) and their role in the provision of health care. This integrative literature review sought to identify and assess the current evidence base for CHs. Methods: A range of electronic reference databases were searched from January 1984 to either December 2004 or February 2005: Medline, Embase, Web of Knowledge, BNI, CINAHL, HMIC, ASSIA, PsychInfo, SIGLE, Dissertation Abstracts, Cochrane Library, Kings Fund website, using both keywords and text words. Thematic analysis identified recurrent themes across the literature; narrative analyses were written for each theme, identifying unifying concepts and discrepant issues. Results: The search strategy identified over 16,000 international references. We included papers of any study design focussing on hospitals in which care was led principally by general practitioners or nurses. Papers from developing countries were excluded. A review of titles revealed 641 potentially relevant references; abstract appraisal identified 161 references for review. During data extraction, a further 48 papers were excluded, leaving 113 papers in the final review. The most common methodological approaches were cross-sectional/descriptive studies, commentaries and expert opinion. There were few experimental studies, systematic reviews, economic studies or studies that reported on longer-term outcomes. The key themes identified were origin and location of CHs; their place in the continuum of care; services provided; effectiveness, efficiency and equity of CHs; and views of patients and staff. In general, there was a lack of robust evidence for the role of CHs, which is partly due to the ad hoc nature of their development and lack of clear strategic vision for their future. Evidence for the effectiveness and efficiency of the services provided was limited. Most people admitted to CHs appeared to be older, suggesting that admittance to CHs was age-related rather than condition-related. Conclusion: Overall the literature surveyed was long on opinion and short of robust studies on CHs. While lack of evidence on CHs does not imply lack of effect, there is an urgent need to develop a research agenda that addresses the key issues of health care delivery in the CH setting